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Obstetrics & Gyn II PDF Abnormal PDF
Obstetrics & Gyn II PDF Abnormal PDF
II
What is Presentation ?
is the part of the fetus which occupying the lower
uterine segment.
During the ANC period It is difficult clinically to
diagnose that the presentation is vertex, brow or
face , so it is used to say cephalic presentation.
What is position ?
is the relation shape of the denominator of the
presenting part to the pelvic brim
2
Vertex
99%
Brow
1:1500
Face
1:500
Introduction
Malpresentation and malpositions are essentially
abnormalities of fetal position, presentation, attitude or
lie.
They collectively constitute the most common cause of
fetal dystocia.
Breech presentation is the commonest
malpresentation.
The other malpresentations are face presentation,
brow presentation, shoulder presentation, and
compound presentation.
The malpositions include occipito - posterior position
and persistent occipito transverse positions.
6
Causes
Before 28 weeks, the fetus is small enough in
relation to intrauterine volume to rotate from
cephalic to breech presentation and back again with
relative ease.
As gestational age and fetal weight increase, the
relative decrease in intrauterine volume makes such
changes more difficult.
In most cases, the fetus spontaneously assumes the
cephalic presentation to better accommodate the
bulkier breech pole in the roomier fundal portion of
the uterus.
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Diagnosis
A. Palpation and Ballottement
Performance of Leopold's maneuvers and ballottement of the uterus may
confirm breech presentation. Diagnostic error is common, however, if these
maneuvers alone are used to determine presentation.
B. Pelvic Examination
During vaginal examination, the round, firm, smooth head in cephalic
presentation can easily be distinguished from the soft, irregular breech
presentation if the presenting part is palpable. However, if no presenting
part is discernible, further studies are necessary (ie, ultrasound).
C. Radiographic Studies
X-ray studies will differentiate breech from cephalic presentations and help
determine the type of breech by locating the position of the lower
extremities. X-ray studies can reveal multiple gestation and skeletal defects.
Fetal attitude may be seen, but fetal size cannot readily be determined by xray .
C. Ultrasound
Ultrasonographic scanning by an experienced examiner will document fetal
presentation, attitude, and size; multiple gestation; location of the placenta;
and amniotic fluid volume. Ultrasound also will reveal skeletal and softtissue malformations of the fetus.
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Diagnosis
Leopolds maneuver reveals round, globular, smooth
head occupying the fundus, which will be ballotable if
adequate amniotic fluid is there and narrow and softer
breech occupies the lower pole of the uterus.
Fetal heartbeat will be heard more easily at or above
the umbilicus.
Pelvic examination in labour identifies the soft
irregular mass with anal orifice, the ischial
tuberosities, genital groove and external genitalia.
In footling and complete breech presentation one or
both feet are felt.
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Management
I. Antepartum management
Breech presentation diagnosed before 32 weeks
of gestation should be managed expectantly
with frequent follow up.
Spontaneous version to cephalic presentation
at the latter weeks of gestation is likely.
After 36 weeks the chance of spontaneous
version is less likely.
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I. Lovset maneuver :
Holding the babys hip rotate the fetus by half a
circle (1800) keeping the back upper most and
applying downward traction at the same time.
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Complications
31
FACE PRESENTATION
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Dx
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Mechanism of labour
The denominator is the mentum (chin). The
presenting diameter is submento- bragmatic
which is 9.5 centimeters.
Eight possible positions exist depending on the
relation of the chin to the various positions of the
pelvis.
34
Management of labour
Caesarian section is indicated in the presence
of big baby, contracted pelvis, previous uterine
scar like previous caesarian section and elderly
primi or woman with bad obstetric history.
Augmentation of labour is generally
contraindicated.
Low forceps may be needed for mentoanterior
position in prolonged second stage.
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BROW PRESENTATION
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Brow
1:1500
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Mechanism of labour
Compound presentation
39
Causes
40
Diagnosis
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Management
Management of compound presentation depends on gestational
age and type of presentation.
Given that 50% of compound presentations are associated with
prematurity, viability of the fetus should be documented prior to
delivery. If the fetus is considered nonviable, labor should be
permitted and vaginal delivery anticipated.
Labor can be allowed and vaginal delivery anticipated in viable
cephalic presentations with a prolapsed hand. These cases
generally pose no difficulty in labor or delivery because the hand
moves upward into the lower uterine segment as the vertex
descends into the birth canal.
Umbilical cord prolapse is a risk in all cases of compound
presentation, and continuous FHR monitoring should be
performed to detect fetal distress or changes in the FHR.
Umbilical cord complications should be managed by immediate
cesarean delivery.
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Diagnosis
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Dx cont.
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Management
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Complications
Cord prolapse
Uterine rupture with possible maternal death.
This is especially true in neglected shoulder
presentation.
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Causes
50
Cont
Generally
Maternal factors are contracted pelvic inlet, multi
parity, tumor.
Fetal factors are malpresentation, long umbilical
cord, low lying placenta, prematurity, multiple
gestation, conditions that cause rupture of
membranes before engagement of the
presenting part like in PROM and
polyhydraminos
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Dx
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Management
I.
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Complications
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Malpositions (vertex-malposition)
Occipito posterior (OP)may be normal in early labor.
Most change by spontaneous rotation to
occipitoanterior position.
Diagnosis is easily made by manual vaginal
examination when one finds the posterior
fontanel directed towards the sacrum.
Women may complain of continuous and severe
backache worsening with contractions.
In the absence of CPD, augmentation of labour
is possible for hypotonic uterine action.
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Shoulder Dystocia
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I- Malpresentation
In the absence of contracted pelvis or/and
big sized fetus most malpresentations and
malpositions do not cause dystocia.
Significant dystocia is a rule in shoulder
presentation, persistent brow presentation,
persistent mentoposterior presentation and
breech with extended head, nuchal arm and
hydrocephalus.
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II- Macrosomia
Macrosomia is defined as fetal weight exceeding 4000
grams.
causes of macrosomia are maternal DM especially of
gestational type and post date pregnancy. Increasing
parity, increasing age are associated with macrosomia.
Macrosomia should be suspected in a woman with
bigabdomen, fundal height of the uterus bigger than
the calculated GA from the LMP, fetus seems large
with minimum amount of amniotic fluid and nonengagement of fetal head at term.
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Pathophysiology
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Management
Goal: Safe delivery before neontal asphyxia
and/or cortical injury
7 minutes!!!
Episiotomy
Suprapubic Pressure
McRoberts Maneuver
Woods or Rubin Maneuvers
Zavenelli
Push back the delivered fetal head into
birth canal and perform an emergent c/s
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McRoberts Maneuver
42% success rate
+ Suprapubic pressure = 54-58%
Brings pelvic inlet and outlet into more vertical
alignment
Flattens sacrum
Cephalad rotation of pubic symphysis
Elevates anterior shoulder and flexes fetal
spine
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HELPER Algorithm
H: Call for Help; Shoulder dystocia is called if
shoulders cannot be delivered with gentle traction
E: Evaluate for Episiotomy: Not routinely
indicated; maybe needed when attempting intravaginal maneuver
L: Legs (McRoberts): Hyperflexion and abduction
of hipsinitial maneuver
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Complications
Maternal
Hemorrhage from genital tract tears and
uterine rupture
4th degree laceration
Fetal
birth injuries Fractures of humerus or clavicle
Brachial plexus injury (Erbs/Klumpkes palsy)
Asphyxia/cord compression and death.
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Others
Malformations that may cause dystocia
include congenital goiter and other neck
swellings, abdominal masses including ascitis,
distended fetal bladder, enlargement of liver,
kidneys and spleen and conjoined twins.
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Bony dystocia
The true pelvis has an inlet, mid-cavity and
outlet. An ideal obstetric pelvis fulfills the
following:
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CPD
CPD means it is difficult or impossible for the fetus to
pass safelly through the mother pelvis due to either to a
matenal pelvis that is too narrow for the fetal head or a
large fetal head relative to the mother pelvis.
Small or contracted pelvis in developming countries like
Ethiopia is generally due to malnutrtion in childhood
persisting into adult life and early marriage.
CPD can not usually be diagnosis before the 37th weeks of
pregnancy because before that the baby head has not
reached birth size.
if the mother s pelvis and the fetal skull are the average
size, there is just sufficient room for the baby s head to
pass through the pelvic canal if the head rotates to present
to the widest dimension of the pelvis
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Contracted pelvis
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Pelvic assessment
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Cont.
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Management
The management of contracted pelvis depends on the
degree of contracture and presence of other obstetric
complications notably malpositions, malpresentations and
macrosomia.
Regardless of other obstetric complications, grossly
contracted pelvis should be managed by caesarian section
preferably electively.
The management of borderline contracted pelvis
depends on the presence of other obstetric
complications.
Caesarian section should be done in the presence of
macrosomic fetus, malpresentation in a normal sized fetus
and conditions which need induction/ augmentation.
In the absence of these a trial of labor should be given
before a decision of caesarian section.
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Trial of Labour
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Delivery
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Case
History
You are asked to see a woman in the antenatal
clinic. She is 37 years old and pregnant with her
third child. Her previous children were both born by
vaginal delivery after induction of labour for post
dates.
First-trimester ultrasound confirmed her menstrual
dates and she is now 36 weeks. At her last
appointment at 36 weeks gestation, the nurse
suspected that the baby was in a breech
presentation. An appointment has been made for
an ultrasound assessment and to discuss the
situation.
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Obstructed labor
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Session objective
At the end of this session students will be able to:
List the main causes of obstructed labour and describe
how each factor contributes to the development of this
complication.
Describe the clinical signs of obstructed labour and the
common maternal and fetal complications that result
from OL.
Describe the management of obstructed labour and
ways of preventing it through your actions.
Explain how social changes at community level could
affect the risk of obstructed labour occurring.
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Obstructed labor
Introduction
Obstructed labor (OL) is failure of descent of
the fetus in the birth canal for mechanical
reasons arising from either the passage or
passenger in spite of adequate uterine
contraction.
The obstruction usually occurs at the pelvic brim,
but occasionally it may occur in the pelvic cavity or
at the outlet of the pelvis.
OL is one of the major causes of maternal mortality
in developing countries
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Causes
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Cont
Passage
Bony pelvis:
Contracted (due to malnutrition)
Deformed (due to trauma, polio)
Soft tissue:
Tumour in the pelvis
Viral infection in the uterus or abdomen
Scars (from female circumcision) Abnormalities
of the reproductive tract
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B. Bandls ring
Bandls ring is the name given to the depression between
the upper and lower halves of the uterus, at about the level
of the umbilicus.
It should not be seen or felt on abdominal examination
during a normal labour , but when it becomes visible and/or
palpable Bandls ring is a late sign of OL.
Above this ring is the grossly thickened, upper uterine
segment which is pulled upwards (retracted) towards the
mothers ribs.
Below the Bandls ring is the distended (swollen),
dangerously thinned, lower uterine segment.
The lower abdomen can be further distended by a full
bladder and gas in the intestines.
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Bandls ring
(a) Normal shape of pregnant abdomen during labour, in a woman lying on her back;
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(a) Normal cervical dilatation and fetal head descent recorded on a partograph.
(b) Cervical dilatation has stopped and the record line has crossed the Action line.
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Rx cont
I.
Rx cont
II. Preintervention preparation
Catheterize the bladder as described above.
Empty the stomach by nasogastric tube.
Determine hemtocrite and blood group. Cross match
at least 1 unit of blood
Give antacids orally
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Complications
The immediate and late complications of OL are responsible
for the high maternal mortality, stillbirth and early neonatal
death
The immediate complications include
Atonic postpartum hemorrhage and Shock
Uterine rupture (rare in primigravidas)
Intra and post partum infection leading to peritonitis, sepsis
and septic shock
Maternal tetanus
Fetal cerebral birth trauma
Fetal distress
Facial injury
Fetal and early neonatal infection and sepsis
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Complication cont
Fistula
Fistula is an abnormal opening (usually as a result
of ruptured tissues) between the:
Vagina and the urinary bladder
Vagina and rectum
Vagina and urethra
Vagina and ureter
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Cont
As a result of the fistula, urine or faeces get into the
vagina and exit in an uncontrolled way.
A woman with a fistual can leak urine or faeces
while walking, or doing any daily activities, and the
waste stains her clothes and creates a bad smell.
Leads to stigmatise or an outcast from the society.
Other consequences of fistula may include constant
depression, and many physical illnesses and
infections of the reproductive tract, bladder and
kidneys, which may even result in the woman taking
her own life.
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Case Study
W/ro Tadelech lives in Mekit Woreda. The journey from
village to city can take days, and she lives far from even a
health post. Tadelech is 25 years old and has already
delivered two children safely in the village. This is her third
pregnancy. Contractions started at 40 weeks of gestation.
After two days of labour Tadelech is carried on a homemade stretcher to your health post. When you examine
Tadelech, finds two swellings (masses) over the abdomen,
with a depression between them at about the level of the
womans umbilicus. You also find that the babys head is not
engaged (it is just above the pelvic brim). On vaginal
examination, you estimate that Tadelechs cervix is 8 cm
dilated and the station of the fetal head is 3. Tadelechs
vagina is hot and dry and she has oedema of the vulva.
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Questions
1. From the case study what signs do you find that
indicate prolonged or obstructed labour?
2. How do you manage Tadelechs condition?
Generally
a. What OL?
b. Mention the cause of OL?
c. Elaborate the Clinical findings of OL?
d. Describe the Rx of OL?
e. How can you reduce the risks of a prolonged and
obstructed labour?
139
Summary
Obstructed labour is failure of descent of the fetus
through the birth canal (pelvis) because there is an
impossible barrier (obstruction) preventing its descent
in spite of strong uterine contractions.
Causes of obstructed labour are CPD, abnormal
presentations, fetal abnormalities and abnormalities of
the maternal reproductive tract.
Causes of prolonged labour are abnormality in one or
more of the three Ps: passenger and passage.
The best diagnostic tool for you to identify prolonged
labour is the partograph.
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Summary cont
The clinical features of obstructed labour include mother
stay in labour for more than 12 hours, exhausted and
unable to support herself, unbalanced vital signs,
dehydrated, Bandls ring formation in the abdomen, bladder
full above the symphysis pubis, big caput and big moulding,
may be edematous vaginal opening
Common maternal complications of obstructed labour
include sepsis, haemorrhage, shock paralytic ileus,
postpartum haemorrhage, fistula formation &death.
Common fetal complications of obstructed labour are
severe asphyxia, neonatal sepsis and death.
Early referral can save the life of the woman and the baby
in case of obstructed labour.
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Thank you!!!
if you have question well come
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UTERINE RUPTURE
Ruptured uterus is defined as a tear in the wall of
the uterus which commonly occurs in the lower
segment of the uterus.
The tear could be anterior, posterior, lateral or
combination of these. It could be transverse,
vertical or combination.
In most, it occurs in the intrapartum period but
antepartum rupture can occur especially in women
with classic/ vertically c/s scar or scars related
to other gynecologic surgeries
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Key
Uterine rupture may occur if the labour is obstructed due to:
Cephalopelvic disproportion
Persistent malpresentation or malposition
Multiple pregnancy (twins or more babies, especially if
they are locked at the neck or conjoined/fused
together).
Physical obstruction preventing the baby from
descending (e.g. a tumour in the abdomen or uterus).
Scarring of the uterus
abdominal massage during labour is a common cultural
practice, particularly when labour is prolonged
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Causes
The commonest cause of uterine rupture is neglected
obstructed labor especially in multipara.
The next common cause is rupture or dehiscence of a
previous C/S scar.
Other causes include
Oxytocin or prostaglandin administration
Difficult instrumental delivery like high or mid forceps
Difficult destructive delivery
Internal podalic version and breech extraction
Difficult manual removal of placenta
Other surgical scars on the uterus(repaired ruptured uterus,
myomectomy)
Vigorous fundal pressure and sharp penetrating trauma
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Answer
Since you use it to chart the frequency and
duration of contractions, as well as changes to
the fetal heart rate, you will quickly see if either
of these is in the warning zone indicated
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Clinical features
C/m Cont
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Management
The life of the patient depends on the speed and
efficacy with which hypovolemia is corrected,
hemorrage is controlled and infection is treated.
In places where surgical intervention cannot be
provided, early referral should be undertaken only after
resuscitative measures are initiated.
When labour ends with a ruptured uterus, the usual
consequences for the woman (if she survives), are
losing her baby and losing her uterus.
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A. Supportive management
This has the objective of initiation of treatment for
impending or full blown shock, intrapartum
infection and preparing the woman for
laparatomy.
Components include:
Opening intravenous line with wide bore cannula.
Vigorous infusion of crystalloids.
Initiation of parenteral antibiotics covering the
mixed organisms like obstructed labour.
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Cont
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B. Definitive management
Immediate laparatomy should be performed.
The surgical options include
total abdominal hysterectomy
sub- total abdominal hysterectomy
repair of the rupture with bilateral tubal ligation
b/c there is an increase risk of rupture of uterus
with subsequent pregnancy the option of
permanent contraceptive need to be discussed
with the women after the emergency is over
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Thank you!!!
if you have question well come
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Definition
precipitous labor terminates in expulsion of the fetus in less
than 3 hours.
Short labors, defined as a rate of cervical dilatation of 5
cm/hr or faster for nulliparas and 10 cm/hr for multiparas,
were associated with abruption, meconium, postpartum
hemorrhage, cocaine abuse, and low Apgar scores.
Maternal Effects
Precipitous labor and delivery seldom are accompanied by
serious maternal complications; if the cervix is effaced
appreciably and compliant, the vagina has been stretched
previously, and the perineum is relaxed.
Conversely, vigorous uterine contractions combined with a
long, firm cervix and a noncompliant birth canal may lead to
uterine rupture or extensive lacerations of the cervix, vagina,
vulva, or perineum.
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Treatment
Unusually forceful spontaneous uterine contractions
are not likely to be modified to a significant degree
by analgesia.
The use of tocolytic agents such as magnesium
sulfate is unproven in these circumstances. Use of
general anesthesia with agents that impair uterine
contractibility, such as halothane and isoflurane, is
often excessively heroic.
Certainly, any oxytocin agents being administered
should be stopped immediately
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Quiz (7minutes )
Discuss on uterine rupture (5pts)
Consider the following Point during your
discussion.
a. what is Ux rupture ?(0.5)
b. Causes?(1)
c. clinical investigations or manifestation (2)
d. Management and prevention(1.5)
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Postdates Pregnancy
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Complications
i) Perinatal Mortality: Research suggests that the
perinatal risk seems to be higher for intrauterine
growth restricted or small for gestational age infants
than it is for average for gestational age infants born
after 40 weeks.
ii) Macrosomia and Shoulder Dystocia
Post-term infants have a higher risk of being
macrosomic, and therefore have a greater risk of
shoulder dystocia.
Shoulderdystocia can cause maternal trauma,
perinatal morbidity (hypoxia, nerve injury, broken
bones, damaged tissues) and in rare cases, perinatal
mortality
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Other Complications
Increased incidence of non-progressive labour
Increased incidence of instrumental delivery
Increased incidence of caesarean section delivery
Contributing Factors
Nulliparity
High BMI
Previous history of postdates pregnancy
Male fetal gender
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Prevention
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Methods include:
- Naegele's rule
- adding 280 days to the first day of the last
normal menstrual period (LNMP)
- adding 266 days to the conception date
- ultrasound dating (more accurate the earlier the
gestation)
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Management Options
Assess
Reviewing EDD.
Reviewing fetal movement count with client
Assess maternal and fetal conditions
Decide on the management with each
advantage and disadvantage
Discuss with obstetrician
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FETAL DISTRESS
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Session objectives
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Definition
Fetal Distress is the sign of inability to
withstand the stress of labor leading to
asphyxia, which if prolonged, places the fetus at
risk of permanent neurologic injury, multiple
organ failure and eventually death.
There is no single indicator that definitely
diagnoses fetal distress but abnormal fetal heart
rate patterns is usually used in the diagnosis.
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Pathophysiology
A normally grown fetus has stored reserves of glycogen
and fat to be used at times of stress like labor.
In labor temporary cessation of placental transfer of
oxygen and nutrients occur during uterine contraction.
This results in anaerobic metabolism with accumulation of
lactic acid and carbon dioxide that increases as labor
progresses.
This is normally corrected between each contraction
provided there is adequate oxygen carrying capacity of
the mother, adequate perfusion of the placenta,
adequate relaxation period between contractions
(resting tonus), good umbilical blood flow (patent vessels)
and adequate fetal energy reserve.
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Cont
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Etiology
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Diagnosis
The diagnosis of FD is usually based on:
I. Abnormal fetal heart rate patterns
An abnormal FHR pattern is associated with high
false positive rate; therefore, it should be used as
a screening method for which additional
methods (scalp PH) are needed for confirmation.
In the absence of confirmatory tests combination of
abnormal patterns should be used to increase the
sensitivity.
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Management
The management of fetal distress has two components
I. Correction of the potential insults
(intrauterineresuscitation)
Put the mother in left lateral position
Start intravenous infusion of fluids(dextrose in saline with
40 %glucose)
Give oxygen by mask at the rate of 8-10 liters/minute
Discontinue oxytocin
Correction of hypotension of regional anesthesia
For cord prolapse put in knee chest position and disimpact
the presenting part
Others - amnioinfusion for cord compression
-acute tocolysis with terbutaline till delivery
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Questions
1. Describe the pathophysiology of fetal distress.
2. Enumerate the causes of fetal distress.
3. Discuss the management of fetal distress
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OPERATIVE DELIVERIES
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Session objectives
At the end of this session student will be able to:
Describe instrumental deliveries (obstetrics forceps
and vacuum extractor).
identify the indications, contraindication,
prerequisites, techniques and complications of
instrumental deliveries.
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Operative delivery
An operative delivery refers to an obstetric
procedure in which active surgical measures are
taken to accomplish delivery in the presence of
maternal and fetal risks.
Operative delivery can be divided into :
I. operative vaginal delivery and destructive
delivery
II. cesarean delivery
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Brain storming
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Instrumental delivery
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Forceps delivery
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Indications
Fetal distress in the second stage of labor
Prolonged second stage of labor: inefficient
uterine contraction or maternal exhaustion or
malpositions.
Maternal conditions which need shortening of
the second stage of labor, where pushing is
contraindicated like cardiac disease, HDP and
previous C/S.
After coming head of breech
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Cont
Prerequisites (for outlet and low forceps)
No gross CPD
Maternal bladder should be empty
Appropriate anesthesia should be given and
prophylactic episiotomy done
Adequate skill and experience
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cathterization
C Cervix
Contmnemonic
F Forceps phantom application
Lt blade , LT hand, maternal Lt side pencil grip &
vertical insertion with Rt thumb directing blade
Rt blade , RT hand, maternal Rt side pencil grip &
vertical insertion with Lt thumb directing blade
Lock blades (If difficulty is encountered, remove
the blades and recheck the position of the fetal head)
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SAMPLE APPLICATION
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SAMPLE APPLICATION
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Contmnemonic
Check application:
Post fontanelle 1cm above the plane of the shanks
Sagittal suture lies in the midline of the shanks
/perpindicular to the plane of the shanks
The operator can not place more than a fingertip
between the fenestration of the blade & the fetal head
on either side
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Contmnemonic
G Gentle traction applied with contraction & maternal
expulsive efforts
H Handle elevated traction in the axis of the birth canal
do not elevate handle to early
I Incision
J Jaw
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Fetal
The fetal laceration of face and scalp,
cephalhematoma, facial nerve injury, fracture of
face and skull, intra cranial bleeding and increased
risk of MTCHT.
Maternal
The maternal complications include tears of
genital tract (perineal, vaginal, and cervical),
episiotomy extension and uterine rupture with or
without bladder rupture.
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Review questions
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Prerequisites:
Indications:
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Contraindication:
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Cont
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Vacuum Application
General Procedure: the procedure of vacuum delivery
is followed as ABCDEFGHIJ mnemonic
A Anesthesia - adequate
- Appropriate positioning & access
B Bladder - cathterization
C Cervix - fully dilated / membranes ruptured
D Determine - position, station, pelvic adequacy
E Equipment - inspect vacuum cup, pump, tubing,
- check pressure
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F Fontanelle
position the cup over the posterior fontal
-ve pressure increase 10 cm H2O initially & between
cont
Sweep finger around cup to clear maternal tissue
Increase pressure to 60 cm H2O with the next
contraction
G Gentle traction
pull with contractions only
Traction in the axis of the birth canal
Ask the mother to push during cont
I incision if needed ?
H handling properly
J- if the Jaw visible remove the cup and control manually
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AXIS ANIMATION
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After determining position of the head, (A) insert the cup into the vaginal
vault, ensuring that no maternal tissues are trapped by the cup. (B) Apply the
cup to the flexion point 3 cm in front of the posterior fontanel, centering the
sagittal suture. (C) Pull during a contraction with a steady motion, keeping
the device at right angles to the plane of the cup. In occipitoposterior
deliveries, maintain the right angle if the fetal head rotates. (D) Remove the
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cup when the fetal jaw is reachable
Mid pelvis
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Pelvic Floor
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Outlet
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Outlet Vacuum
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Cont
As soon as the head is delivered release the cup and
complete the delivery of the fetus and the placenta.
Following the delivery of the placenta, inspect
the lower genital tract for tear and episiotomy for
extension. Repair episiotomy and any tear.
Provide care for the neonate and check for
complications on the neonate.
Document your findings
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Complications
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Molding
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Hematoma
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vacuum demo.FLV
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Review questions
1. List the indications of vacuum delivery.
2. List the prerequisites to vacuum delivery.
3. List the complications of vacuum delivery.
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Destructive delivery
Session objectives
At the end of this session student will be able to:
Name the types destructive deliveries
Describe the prerequisites for destructive deliveries
Identify complications of destructive deliveries
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Destructive delivery
Destructive delivery is vaginal operative delivery that
accomplishes delivery of the fetus by reducing its
size in a woman with obstructed labour with dead
fetus.
The advantages of destructive delivery over C/S
for a woman with OL and fetal death are:
The uterus will remain intact, thus avoids the risk
of rupture of the uterus in the subsequent
pregnancies.
Peritoneal contamination by infected uterine contents is
avoided
Risks of anesthesia and prolonged postoperative stay
in bed are avoided
241
I.
242
243
244
245
Prerequisites
Clear indication- obstructed labour (gross CPD,
impacted shoulder presentation, shoulder presentation)
Fully dilated cervix
Dead fetus (need to be confirmed by ultrasound or
auscultation by three people)
Accessible presenting part for the type of procedure
selected ( head with decent of < 2/5 for craniotomy, neck
for decapitation, axilla or abdomen for evisceration)
Imminent rupture or rupture of the uterus ruled out
Access for immediate laparatomy and blood transfusion
Adequate skill and ansthesia
246
Complications
247
Review questions
248
249
Session objective
At the end of this session student will be able to:
Describe the major types of caesarian section
with their advantages and disadvantages
List the major complications of caesarian section
250
Brain storming
251
Primary
Repeat
252
254
255
Cont
Therefore it is not a routine method of C/S
and is only done upon specific indications.
Inaccessible lower segment because of dense
adhesions from previous caesarian section
Large myoma over the lower segment
Highly vascular lower segment from anterior
placenta previa
Fetal malformations like conjoined twin and
transverse lie with back down
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257
Indications
258
Cont
Conditions with unripe cervix where rapid
delivery is needed like preeclampsia,
ecclampsia,
Previous C/S after failed trial of scar or electively
Carcinoma of the cervix
The X-factor relative indications, which
considered separately, might not warrant C/S
but when taken together constitute a valid
indication. Example is post term plus elderly
primigravida or prior infertility problem.
260
Cont
Both inhalational (general) and regional (spinal,
epidural) ansthesia can be used.
Proper preparation of the operative site is done.
Abdomen is opened by midline, paramedian or
transverse suprapubic incisions.
Fetus is extracted .
The cord is clamped and cut. The placenta is
delivered.
262
Cont
263
Postoperatively
264
Complications
265
Cont
266
Review Questions
268
Obstetric Shock
Session objective
At the end of this session student will be able to:
Identify the major types of obstetric shocks with
their Pathophysiology and clinical manifestations.
Describe management options for mother which
develops obstetric shocks (Resuscitation and
Special Circumstances
270
Introduction
Shock
One of the most common causes of death
Shock and Respiratory Failure together
account for majority of emergent ICU admissions
Shock mortality is high
271
Brain storming
272
Shock - Definition
Functionally, Shock represents a clinical
condition in which intravascular volume (and/or
perfusion) is below intravascular capacitance
(and/or demand)
Operationally, Shock is broadly divided into
three types:
Hypovolemic
Cardiogenic
Neurogenic
273
Shock - Obstetrics
274
Shock - Pathophysiology
275
Hemorrhagic = Hypovolemic
Leading cause of Obstetric death
Significant cause of morbidity during pregnancy
and immediately postpartum
May be poorly recognized due to physiologic
changes of pregnancy
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Postpartum Hemorrhage
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278
C/S
Hypotension
Signs of Organ Hypoperfusion
Mental Status Changes
Oliguria
Lactic Acidosis
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281
282
283
284
Septic Shock
Septic (defined earlier) associated with documented
infection is termed SEPSIS
Severe sepsis indicates the presence of organ
dysfunction, hypoperfusion, and/or hypotension
Septic shock consists of severe sepsis refractory to
volume resuscitation
Multisystem dysfunction syndrome (MODS) is the
terminal phase of this sequence of events
285
Cont
286
287
288
Mediator Release
Cell Injury
ARDS
Hypotension Acidemia
Impaired Immunogenic
Response
289
Review questions
292
Version
Version is a procedure used to turn the fetal
presenting part from breech to cephalic presentation
(cephalic version) or from cephalic to breech
presentation (podalic version).
cephalic version is performed by manipulating the
fetus through the abdominal wall, the maneuver is
known as external cephalic version.
Podalic version is performed by means of internal
maneuvers and is known as internal podalic
version.
External cephalic version is regaining popularity,
whereas internal podalic version is rarely used
293
Indications
Patients with unengaged singleton breech
presentations of at least 36 weeks' gestation are
candidates for external cephalic version.
The procedure is more successful in multigravidas
and those with a transverse or oblique lie.
Use of fetal heart rate monitoring and real-time
ultrasonography are essential to document fetal
well-being during the procedure.
The use of tocolytics in external cephalic version is
controversial.
295
Contraindications
Contraindications to external cephalic version
include engagement of the presenting part in the
pelvis, marked oligohydramnios, placenta
previa, uterine anomalies, presence of nuchal
cord, multiple gestation, premature rupture of
membranes, previous uterine surgery (including
myomectomy or metroplasty), and suspected or
documented congenital malformations or
abnormalities (including intrauterine growth
retardation).
296
Complications
Complications are rare, occurring in only 12% of all
external cephalic versions.
Complications include placental abruption, uterine
rupture, rupture of membranes with resultant
umbilical cord prolapse, amniotic fluid embolism,
preterm labor, fetal distress, fetomaternal
hemorrhage, and fetal demise.
Thus, given the potential for catastrophic outcome,
this procedure should be performed in a facility where
immediate access to cesarean delivery is available.
Patients require extensive counseling regarding the
version procedure, with disclosure of all risks,
benefits, and alternatives so that an informed
medicolegal decision can be made.
297
Technique
External cephalic version is performed as follows:
1. Obtain informed consent from the patient.
2. Perform an ultrasound examination to verify presentation and to rule out fetal
or uterine abnormalities.
3. Perform a nonstress test. Results must be reactive.
4. If desired, administer a tocolytic to prevent contractions or irritability.
5. dminister anesthesia if desired.
6. Perform ECV. Place both hands on the patient's abdomen, and perform a
forward roll by lifting the breech upward while placing pressure on the head
downward toward the pelvis. If this maneuver is unsuccessful, a backward roll
can be attempted.
7.
Fetal well-being should be monitored intermittently with Doppler or real-time
ultrasound scanning. The procedure should be abandoned in case of any
significant fetal distress or patient discomfort, or if multiple attempts are
unsuccessful.
8. Following the procedure, external FHB monitoring should be continued for 1
hour to ensure stability. If the patient is Rh-negative, administer anti-D immune.
9. If the patient is stable, she can be sent home to await the onset of
spontaneous labor if the version is successful. If unsuccessful, the patient can
be scheduled for an elective cesarean section or a trial of labor with a breech
vaginal delivery planned if the mother is a good candidate.
300
301
Indications
Internal podalic version is the only alternative to cesarean
section for rapid delivery of the second twin in a
noncephalic presentation if external cephalic version fails.
Thus, when cesarean section is unavailable or when a lifethreatening condition arises (maternal hemorrhage due to
premature placental separation, fetal distress, prolapsed
umbilical cord), internal version may be required.
A life-threatening condition is the only indication for internal
podalic version. The cervix must be completely dilated, and
the membranes must be intact. A skilled operator is crucial
for safe performance of this procedure. In several French
studies, internal podalic version was found to be a reliable
and effective technique with excellent long-term maternal
and fetal prognoses.
302
Contraindications
Internal podalic version is contraindicated in cases
in which the membranes are ruptured or
oligohydramnios is present, precluding easy
version.
This procedure should not be performed through
a partially dilated cervix or if the uterus is firmly
contracted down on the fetal body.
However, recent studies have indicated that
intravenous nitroglycerin can be used to provide
transient uterine relaxation without affecting
maternal or fetal outcome.
303
Complications
Internal podalic version is associated with considerable
risk of traumatic injury to both fetus and mother
associated uterine rupture and hemorrhage caused 5% of
all maternal deaths.
Perinatal mortality rates were 525% (primarily due to
traumatic intracerebral hemorrhage and birth asphyxia).
Considerable birth trauma, including long bone fractures,
dislocations, epiphyseal separations, and central nervous
system deficits, was also linked to this procedure.
For these reasons, internal podalic version has been
abandoned with rare exceptions in favor of cesarean
section.
304
Technique
Internal podalic version is performed as follows:
1. Establish an intravenous line for administration of
parenteral fluids, including blood. Cross-matched
blood should be available in the hospital blood bank.
2. Administer anesthesia to achieve relaxation of the
uterus.
3. Place the patient in the dorsolithotomy position. Insert
a hand through the fully dilated cervix along the fetal
body until both feet are identified, and apply traction
to bring the feet into the pelvis and out the introitus.
Then, grasp both feet firmly. Perform an amniotomy.
Apply dorsal traction on both lower extremities until
both feet are delivered through the vagina. Then,
perform a total breech extraction for delivery of the
body
305